A IMS – ACUTE BLOCK CURRICULUM Falls Diagnose the cause of falls in the elderly by history, examination, appropriate use of investigations Acute Confusion Differentiate acute from chronic confusion Common causes Initiate management of commoner causes
O BJECTIVES Be able to assess an older adult following a fall. Formulate differential diagnosis Be able to investigate an older adult following a fall Be able to assess an older adult with confusion. Know how to investigate and initially manage acute confusion
W HY ARE OLDER PEOPLE AT RISK OF FALLS ? Frailty Reduced physiological reserve and weakness Multiple medical problems Polypharmacy Social adversity
Dear Doctor, Re: Mr A. Notherfall Thank you for seeing this 82 yr old gentleman who collapsed at home. Has fallen before. PMH: HTN Yours sincerely C ASE 1
H ISTORY - HPC What questions would you ask and why? Frequency/time course What were they doing before they fell? From sitting to standing, turning of head Preceding symptoms SOB,CP, palpitations Light headed Room spinning Unsteady on feet
LOC? Do they actually remember falling, hitting the floor etc How long were they unconscious for? Any suggestion of fit? Was it witnessed? How long were they on the floor for? could they get themselves up? If mechanical – any precipitants? Any injury?
Think back to an older patient you have taken a history from....
Difficult due to: Multiple pathology and aetiology Atypical presentation Cognitive impairment Sensory impairment
A BBREVIATED M ENTAL T EST S CORE Age Date of Birth Time (to nearest hour) Short term memory (“42 West Street”, recall at end) Recognition of 2 persons (e.g. doctor, nurse) Current year Name of place they are in Dates of WW2 Name of present monarch Count back from 20-1 <8/10 = Cognitive impairment Needs further assessment!
A COLLATERAL HISTORY IS A MUST ! Relatives Paramedics – ambulance sheet Care home staff Nurses/Health care assistants GP (prescription) DOCUMENT IT!
C AUSES OF FALLS Medical Cardiac Neurological Orthostatic hypotension Drug related Gait Balance vertigo Environment Clutter, footwear, pets, lack of grab rails InternalExternal
S YNCOPE Transient, self limiting LOC, rapid onset, spontaneous, complete, prompt recovery Transient impairment of cerebral blood flow Symptom NOT diagnosis CARDIAC ORTHOSTATIC HYPOTENSION NEURALLY MEDIATED
E XAMINATION FOLLOWING A FALL (ABCDE) Any injury? Cardiac Pulse Murmurs? Assess fluid status Postural BP Neuro Motor weakness Sensory impairment Coordination Gait Cognition
I NVESTIGATIONS AFTER A FALL Bloods: FBC, U&E, Calcium, Glucose, CRP Vitamin B12, Folate, TSH ECG Urine analysis Only if specifically indicated: 24 hour ECG Echocardiogram Tilt-table testing CT head EEG
I NVESTIGATIONS 12 lead ECG + postural BP (together) Provides diagnosis in 2/3 rd cases Echocardiogram If murmur and clinically suspect relevant 24 hour ECG Very low yield (<1%) Specifically best in people with daily symptoms, even then <30%
A CUTE C ONFUSION
C ASE 2 A 78 year old woman is found by her neighbours confused and wandering in the street at night wearing her night clothes. In the emergency room she appears unkempt and dishevelled. She is alert, but disoriented in time and place and cannot recall her home address. She engages well with questions, but tends to shift the conversation to stories about her husband and children. She is admitted to hospital and wanders around the ward appearing lost and, when asked, says that she is looking for a bus stop to go home How would you assess her?
H OW WOULD YOU ASSESS HER ? AMTS Collateral history Confusion Assessment Method for Delirium A) Sudden onset/Fluctuating Course Hrs-days? Change from patient’s baseline? Come and go? B) InattentionUnable to focus Doesn’t keep track of what is asked Difficulty following demands C) Disorganised thinkingRambling/irrelevant conversation Illogical flow ideas Switching from subject to subject D) Altered level of consciousness Hyperactive/agitated Quite/withdrawn Drowsy Reversal normal sleep-wake cycle common
D EMENTIA VS DELIRIUM Insidious (months-yrs) Progressive No(less) fluctuation Attention ok Conscious level ok Sudden, may be reversible Greatly impaired attention and consciousness DementiaDelirium
W HAT ELSE WOULD YOU WANT TO FROM THE HISTORY ? Symptoms of underlying cause Drug history Alcohol use Signs of infection Fever, crackles, abdo pain, PR?? Alcohol withdrawal O N EXAMINATION ?
W HAT ARE THE DIFFERENTIALS ?
D ELIRIUM - CAUSES Often multi-factorial Fluid and electrolyte disturbances Infections (UTI, resp, soft tissue) Drug or alcohol toxicity Withdrawal from alcohol Metabolic disorders Hypoglycemia, hypercalcemia, ureamia, liver failure, thyrotoxicosis Postoperative states, especially in the elderly Accentuated on admission by unfamiliar hospital environment
H OW WOULD YOU INVESTIGATE ? Bedside: BM Urine dipstick Bloods: FBC, U+Es, LFTs, Glu, Ca, TFTs Blood cultures ECG Imaging CXR CT?? Obs and MEWS hypoxia hydration early sepsis
CT HEAD IN DELIRIUM Often not helpful New focal neurologic deficit New seizure Head trauma Fall Low platelet count or coagulopathy
I MAGING IN DELIRIUM
T HINK ABOUT COMPLICATIONS OF ACUTE CONFUSION Falls Pressure sores Continence Feeding
C ASE 3 78 woman is admitted with delirium due to pneumonia. She is pulling at her IV cannula and taking her oxygen mask off. How would you manage the patient?
M ANAGING DELIRIUM Environment - lighting Maintain orientation Encourage family Minimise shift changes (familiarity) Bowels/bladder addressed Pain addressed Avoid restraints – causes more chance of injury
S EDATION IN DELIRIUM Sedation When above has failed Comes with risks Resp depression Increased falls (hangover) 1 st line haloperidol (0.5 – 1mcg) Risperidone also Lorazepam 2 nd line See guidelines on intranet
T AKE HOME MESSAGES Importance of a good history & collateral Determine the acute event that has precipitated the admission (often on a background of ‘problems’) Thorough examination and tailor investigations Think about medium-long term